A recent review of the state of the art in quality improvement concluded there have been real improvements in surgical mortality and hospital-acquired infections, and perhaps in readmissions, but many barriers remain. First, high-value care is far from universal, being a prominent focus in public programs, but not in private ones. Care delivery is fragmented and so are quality improvement efforts. As a result, care is not patient-centered. Second, health equity concerns are growing. Mortality in Latino and black populations is consistently higher than in white populations. Maternal mortality if five times higher as is opioid use disorder and drug overdoses. One third of ED visits are by homeless people, 20% of the elderly are socially isolated, and one in six children lacks food security. Despite these issues, the authors assert the goals of the Institute of Medicine, (STEEEP) remain foundational, although they agree that “patient-centered care” is evolving more toward “person-centered care,” and “effective” care needs to be changed to “appropriate care” in recognition that much care is not appropriate to the needs of the individual.
The following two questions are often posed to quality improvement professionals. If progress is there, why not everywhere? If progress exists on that problem, why not all problems? They conclude:
“It is time…to realize that changes in culture, investment, leadership, and even the distribution of power are more important for progress toward the Triple Aim than measurement, alone, ever was or ever will be.”
Naturally, I agree as this has been central to the articles posted on this website, but I also agree we need to keep the best parts of the quality movement while relieving it of the burden of being the only tool in our kit to make care better. But the short-comings listed are “wicked problems” and do not admit of easy solutions. Besides, any efforts to attain high value care must take place in the context of a strained health care system that has been disrupted by a foreseeable problem—the pandemic. No, we could not know when, but this is not the first, and will not be the last, time to deal with epidemic disease; it is just more severe than some of the more recent ones.
So, what should leaders of our healthcare organizations be doing? I found some interesting advice on how leaders should react, (but not what should be done.) The authors suggest five steps. First, stop and take a deep breath. Second, involve more people, not fewer. Third, make the critical small choices. Fourth, set up a mechanism to delegate tasks to teams and provide central coordination, and fifth, empower leaders with judgment and character. They suggest looking for leaders who have survived a personal or professional crisis already, have made highly unpopular decisions because they thought it was the right thing to do, even if it harmed their career chances, or were willing to give bad news up the chain of command. Of course, as they note, these are precisely the behaviors that are punished in “normal times” in every large organization.
Their most important observation, though, is the distinction between strategic decision-making and tactical decision-making.
“A strategic decision comes with a high degree of uncertainty, a large likelihood that things will change, difficulty in assessing costs and benefits, and a result of several simultaneous outcomes. A tactical decision comes with a clear objective, a low degree of uncertainty, and relatively clear costs and benefits. Tactical decisions are important—sometimes crucial. Yet they are often better left to those on the edges of the organization who can act effectively without raising the issue to higher levels.”
The pandemic has shown just how fragile most of our healthcare organizations really are. We have been reminded that healthcare is highly regulated and has developed a highly bureaucratic structure in response. Consider this. Two of the three organizations I spent my career with entered into corporate integrity agreements with the government after reporting self-discovered billing errors as required by law. Each of these programs added yet another layer of bureaucracy, this time to mitigate penalties for future “compliance” failures. But the system is so mind-numbingly complicated that future failure is inevitable, so the compliance programs take on a life of their own.
We have also re-discovered just how critical “elective” surgery is for financial health. The forced closure of operating rooms has resulted in massive cash flow issues and lay-offs in most large hospitals, which combined with expenditures for supplies and staff to treat coronavirus-infected patients has caused major losses. Those without strong balance sheets are likely to collapse at the very time their communities need them most.
Our current state, then, can be defined as a system that is fragmented with many of the stakeholders burdened by financially fragile, bureaucratically rigid organizations with much of their “value” in hard assets like buildings and equipment, yet short on intellectual capital, leadership, and organizational and clinical resilience. Making organizational changes to improve outcomes that matter is a strategic decision with all the uncertainty associated with it. It behooves all stakeholders to ask themselves some key questions. What is my organizational purpose? How does my organization contribute to the health of our community? What is our community? Who else in our community has a role to play? How can we interact with these other stakeholders productively and how do we know? There are many possible “right” answers to these questions, but organizations likely to survive the crunch will have their senior leadership meeting with relevant parties to develop consensus answers to these questions. I also think it important that we not “medicalize” problems—it limits our thought processes. Many of our current failures are social and only become medical later. Other ways of thinking have value. If we do not find ways to access those other ways of thinking, medical organizations run the risk of making the medical equivalent of buggy whips.
8 June 2020
 D’Avena A, Agrawal S., Kizer KW, Fleisher LA, Foster N, Berwick DM> Normalizing high-value Care: Findings of the National Quality Task Force. 1 May 2020. Accessed 7 May 2020 at https://catalyst.nejm.org/doi/full/10.1056/CAT20.0063.
 Fleisher LA, Foster N, Berwick DM. A Review of the National Quality Measurement and Report System: How to Finish Its Aim. 1 May 2020. https://catalyst.nejm.org/doi/full/10.1056/CAT20.0063.
 Alexander A, DeSmet A, Weiss L. Decision Making During the Coronavirus Crisis. McKinsey and Company, 24 March 2020. Accessed 6 June 2020 at https://www.mckinsey.com/business-functions/organization/our-insights/decision-making-in-uncertain-times#
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